The influence of household structure and composition on the introduction of solid, semisolid and soft foods among children aged 6–8 months: An analysis based on Ethiopia Demographic and Health Surveys

Abstract The early and late introduction of complementary food, both prevalent in Ethiopia, are associated with morbidities, growth faltering and developmental risks in children. The interhousehold network around the primary caregiver's intrahousehold network is critical in influencing the age of introducing complementary foods. This study examined the influence of household composition and structures on complementary food introduction. This is a secondary data analysis of four Ethiopian Demographic and Health Surveys conducted between 2000 and 2016. The household structure and composition variables were calculated from household members' kinship status and attribute, respectively. The introduction of solid, semisolid or soft foods was dichotomised as whether the children within 6 to 8 months have been given complementary foods. Multivariable logistic regression with adjustment for the primary caregiver and household characteristics was run to examine the associations between household structure and composition variables and the introduction of complementary foods. The marginal effects (ME) were calculated to facilitate the practical interpretation of the study findings. Large households (>3 nonredundant contacts) with extended family or unrelated people (high effective size, ME = 6.01%, 95% confidence interval [CI]: −8.53, −3.49) lowered the proportion of children starting food within the recommended 6–8 months. Households with close kins (high constraint) (ME = 7.22%, 95% CI: −13.65, 28.09) and greater age diversity (ME = 0.65%, 95% CI: 0.15, 1.15) increased the proportion of children receiving complementary food at an appropriate age. This study revealed that interhousehold structure and composition influence the age of introduction of complementary foods. These factors, therefore, need to be considered in designing interventions to improve age at the introduction of complementary foods.


| INTRODUCTION
Multiple burdens of malnutrition, including undernutrition, overnutrition and poverty, have become integral problems in lowincome countries (Haddad et al., 2015). In Ethiopia, stunting driven by suboptimal feeding practices, among other causes, affects more than two of five children, and undernutrition accounts for 28% of child deaths (FDRE, 2013). One of these feeding practices against the recommendation is the age of introduction of complementary foods, measured by the proportion of children 6-8 months given solid, semisolid and soft foods in the last 24 h (WHO, 2008).
At 6 months of age, breast milk alone can no longer meet child nutritional requirements, and early and late introduction of solid food carries growth and development risks (WHO, 2008).
However, the proportion of Ethiopian children starting complementary food within the appropriate age range (6-8 months) remains a problem, with a pooled national prevalence of 62.5%, which increases with women giving birth at health care institutions and lower among working women (Habtewold et al., 2019;Yeheyis et al., 2016).
The prevalence of timely introduction of solid food varies according to geographical location, with 53% to 72% of infants living in predominantly rural areas introducing solid foods in a timely way (Anteneh et al., 2017;Biks et al., 2018;Kassa et al., 2016;Kim et al., 2016) compared to 55.2% to 83% in the capital. This is largely attributed to the higher educational status of those living in urban areas (Mohammed et al., 2018;Yeheyis et al., 2016). Complementary foods are delayed among food insecure rural Ethiopia households due to knowledge gaps on ageappropriate complementary feeding practices (Hirvonen et al., 2021). While there is no recommendation, according to the United Nations Office for the Coordination of Humanitarian Affairs (OCHA), less than 80% of children meeting this criterion are considered a public health priority (OCHA, 2021).
Averting undernutrition and enhancing children's survival requires focusing on multiple interventions within enabling environments, including the household (Black et al., 2020). The household is the most proximal setting where thriving can be promoted by delivering responsive care, safe and nutritious foods, health care, learning opportunities, safety and security (Black et al., 2020).
In a broader sense, the pathway from the household composition and structure to optimal nutrition is mediated by adults' physical presence and attention to the child. Adults can be missing from the family due to marital dissolution, working away from home (Coleman, 1988), underreported orphanhood during early life (Robertson et al., 2008) from HIV/AIDS (Kebede et al., 2000;Mirkuzie et al., 2020), the high maternal mortality rate (Tessema et al., 2017) or other causes (UNICEF, 2022). The absence of adults leads to an environment where the child's nutrition is at risk (MacDonald et al., 2020).
The mothers/primary caregivers are the ultimate decisionmakers for infant feeding among household members (Benoit, 2004). However, maternal decisions occur within a household context where other actors may exert their influence (Dewey, 2003). Thus, it can be theorised that while a mother's physical presence is essential to promoting an infant's optimal nutrition, it may not be sufficient, as infant feeding may be hampered or facilitated by others within the network (Abebe et al., 2019;Coleman, 1988;Federal Ministry of Health, 2004;Lucas et al., 2018).
Thus, the role of the mother's intrahousehold social network is critical around the age of 6 months when complementary foods must be started (WHO, 2008). The timing of introduction might be guided by social norms related to parenting practices, gender, local culture, the types of support the mother/caregiver obtains and household members' roles (Bililign et al., 2016;Kinabo et al., 2017;Mekonnen et al., 2018;Reda et al., 2019;Tamiru et al., 2013). The cumulative effect of these factors on the timing of the introduction of solid foods shapes the diet composition, patterns, current and future food preferences, habits and wellbeing of the child (Adair, 2012;Owino, 2019).

Key messages
• In a large family, women with extended and nonrelated household members had a 6% reduction in the proportion of children starting complementary food within 6-8 months.
• To our best knowledge, the negative influence of unrelated household members has not been reported before. Future studies might examine their roles and how this household subpopulation can be enabled to support optimal infant feeding.
• The higher constraint emanating from the interdependence of close kins as in a nuclear family or small household with extended members was associated with a 7.2% increment in the proportion of children starting complementary food at an appropriate age.
Household members also undertake diverse child feeding roles based on their age, sex and kinship status. For instance, support obtained from fathers' (Reda et al., 2019) improves the timely initiation of complementary foods in Ethiopia (Biks et al., 2018;Kim et al., 2016). Further, in a study conducted in Southern Ethiopia involving 764 caregivers in 2009, four out of five caregivers were biological mothers, and they preferred using a responsive feeding style (Wondafrash et al., 2012). In contrast, nonbiological caregivers practised laissez-faire feeding styles, characterised by minimal child encouragement to eat, irregular child feeding patterns and timing of feeding (Dettwyler, 1989;Wondafrash et al., 2012).
Overall, early or late complementary feeding is an individual decision (Underwood & Hofvander, 1982) driven by social factors and opportunity rather than meeting the child's nutritional requirements (Przyrembel, 2012). Addressing social factors in infant feeding practices is a high priority for the Ethiopian Government. The National Infant and Young Child Feeding Strategy recognises the need to focus beyond the mother-child dyad to involve fathers and other household members via companionship, access to accurate information and caring (Federal Ministry of Health, 2004;Przyrembel, 2012). This focus builds on research that shows that improving fathers' (Mukuria et al., 2016) and grandmothers' knowledge (Karmacharya et al., 2017;Mukuria et al., 2016) of infant feeding translates to better infant feeding practices by the mother.

Previous Ethiopian Demographic and Health Survey (EDHS)
analysis and other studies on determinants of the introduction of complementary feeding have focused on individual-level factors, including maternal, child, paternal or other family members or household attributes (Ahmed et al., 2020;Przyrembel, 2012). Studies have not explored the introduction of complementary foods from the broader household environment, including the parent-child dyad and the composition and structure of households. This information is important in understanding persistent suboptimal practices and will inform opportunities to support healthy child development within Ethiopian households. Hence, this study will provide an in-depth analysis of the influence of household composition and structures and associations with the introduction of solid, semisolid or soft foods between ages 6 and 8 months. The DHS Program approved the data access on April 13, 2020.

| Variables
Variable selection was based on a conceptual framework of determinants of feeding practices for children older than 6 months developed by Hector et al. (2005) as cited by Blaney et al. (2014Blaney et al. ( , 2015. The outcome variable is the introduction of solid, semisolid or soft foods and exposure variables related to household composition and structure variables as described below.

| Introduction of solid, semisolid or soft foods
This is one of the core indicators for infant feeding practices, defined as the proportion of infants 6-8 months who received solid, semisolid or soft foods. The indicator value was derived from questions administered to the child's primary caregiver after variable was analysed as a binary variable: whether or not to receive solid foods at 6-8 months of age.

| Women's intrahousehold network measures
The analysis focused on the social network around the women respondent, the primary caregiver (the mother or other women in IRENSO ET AL. | 3 of 13 the household) who responded to the infant and young child feeding questionnaires. The EDHS household roster used to collect the data contains 20 lines, including the women respondents and their demographic information, including age, sex, education and relationship to the household's head and coresidence status. These variables were used to calculate the composition and structure variables. In this analysis, women respondents are referred to as egos. Any other individuals listed on the household roster are referred to as an altar, and the relationship among them, alter-alter tie. The social network measures were derived using E-Net version 0.050 (Borgatti, 2006) and imported to Stata 15 (StataCorp, 2013) for further analysis.

| Household composition measures
The index of qualitative variation (IQV) was calculated to estimate the alters' heterogeneity based on categorical variables, such as people with diverse relationships, usual household residents (de jure members), actual household residents (defacto members), sex and educational status. E-Net software provides two summary diversity measures, Blau index (H) and IQV (Borgatti, 2006). Suppose the variable has r number of different categories and P i is the proportion of categories in variable i, then the Blau index H is: The IQV is a normalised version of the Blau index weighted for the number of categories, calculated as follows (Crossley, 2019): De facto members are people who actually slept in the household the night before the data collection, including visitors.
Most household members are both de jure and de facto, that is, those usual members who stayed in the household the night before the survey. However, some are de facto but non de jure (e.g., Visitors), which gives IQV of the de jure figure; a visitor means diversity to usual household members. Other household members are de jure but nondefacto, that is, a usual household member staying away from home gives diversity to those staying at the household, the IQV of de facto members.
The IQV Ranges from 0 to 1, with higher scores, indicating more heterogeneity (0 = all alters in the same category; 1 = alters equally dispersed across all categories) (Solanas et al., 2012

| Covariates
Covariates include the respondent's (all are women) characteristics (Chen, 2013), such as residence (urban/rural), educational status, age, occupation, sex of households' head and overall household characteristics of socioeconomic status, the wealth index.

| Statistical analysis
All analyses were conducted in STATA 15 with statistical significance set at p < 0.05. Sampling weight was considered in all analyses using 'svy' command. The introduction of solid, semisolid or soft foods and other categorical variables were described using percentages.
Continuous variables were described using mean and SD or the median with 25th and 75th percentile.

| Factors associated with introduction to solid, semisolid or soft foods
Overall, the effective size (the number of alters adjusted for similar kinship categories) significantly decreased the odds of introducing solid semisolid and soft foods at 6-8 months (   Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; COR, crude odds ratio; IQV, index of qualitative variation.
a Crude model includes each family structure and composition variable as the exposure and introducing the child to solid semisolid and soft foods as the outcome using 'svy'.
b Adjusted model adjusted for covariates including women's age in years, educational status, residence, coresidence with husband/partner, sex of household head, wealth index and type of earnings using 'svy'.
c Overall OR was calculated with multilevel mixed-effects logistic regression modelling specifying survey year as a random effect. d The average marginal effect was calculated for each variable as the discrete change from the reference value for categorical variables (effective size, de facto family members and de jure family members) and a probability of children introduced to solid, semisolid and soft foods with a small change for continuous variables from the multilevel mixed-effects logistic regression model.
*p < 0.05; ***p < 0.001. household decision-making dynamics of homogamy where the child's parents are of similar background, including low economic and educational status, cultural background and parental attitude.
These similarities may mean that these families are more likely to follow traditional practices that are contrary to optimal infant feeding. Thus, homogamy is common in Ethiopia and potentially perpetuates existing incorrect feeding practices (Kalmijn, 1998).
Our findings showed that nonrelative household members modify the household structure and negatively influence the timing of the introduction of complementary foods. Evidence shows that nonrelated people come to the household as domestic servants (Biadegilegn, 2011).
In Ethiopia, domestic workers comprise 3.3% of all employment, higher for females at 5.3% than males at 1.6%. Most of these female domestic workers reside in their employer's household, undertaking household chores and child caregiving (ILO, 2022). Domestic workers, for instance, in Addis Ababa, are adolescents, migrate from rural to urban areas and are less educated (Erulkar & Ab Mekbib, 2007). These unrelated people are heavily involved in childcare. However, their involvement in child feeding activities and practices has never been assessed in Ethiopia. Based on these premises, domestic servants are a stealth subpopulation to be considered in infant feeding. Further research describing the impact of this group on child feeding is required.
Among household composition variables, women whose alters are of different ages (age diversity) and had a better chance of offering complementary food on time. Age is one of the social categorisation variables in determining group membership. In social categorisation, people close in age to the mothers might seek and share similar messages and act similarly, providing peer support in the household. With increasing adult age diversity, the presence of both old and young alters might limit the acceptance of suggestions of older household members (McNicoll, 2002), such as food distribution traditions that prioritise elders and husbands (Berhanu et al., 2019) and the early introduction of complementary food for boys but not girls (Andrysek et al., 1984). Evidence shows a growing sentiment among the older generation that their long-held norms are undervalued (Adamek et al., 2019).
This study shows that in households with even distribution members across kinship types, the better timing of introducing complementary food, the association between IQV of kinship types and the introduction of solid, semisolid and soft foods from negative in 2000 to positive in later survey rounds. One possible explanation for this might be related to opinion diversity that converges to a more positive deviant behaviour, which corresponds to national policy such as the implementation of the Health Extensions Programme in 2004, which brought better access to health prevention services compared to the year 2000 (Banteyerga, 2011). As an alternative explanation, this study showed that women's educational status has improved over subsequent survey rounds, hence more empowerment to choose and make the right decision, even with conflicting messages from household members (Berhane et al., 2001). Hence, households of multiple generations are likely to be more supportive and empowered, and the role of household members, such as the senior members, deviates from positive behaviours.
Modifying existing practices requires understanding cultural community (Kalra et al., 2018). The introduction of complementary food provides an opportunity for early food acculturation, socialisation of the infant into the household and community foods. In the process of introducing the child to foods, other household members observe, learn and preserve the practices (Palmer, 2011 showed barriers (e.g., nonrelatives and extended members in large households) and facilitators (e.g., nuclear family households) to translating intrahousehold networks around the mother by supporting her and improving infant feeding practices. For instance, supporting women's nutrition during pregnancy improves infant feeding (Dewey, 2001) by reducing the perception that the newborn is small (Issaka et al., 2014) and that the breast milk is insufficient for the baby, a common justification for the early introduction of food; these claims are reinforced by the grandmothers and other females in the household (Kalra et al., 2018). Further, economically disadvantaged caregivers (Hazir et al., 2012), women with less frequent antenatal care (Andrysek et al., 1984;Hazir et al., 2012) and fewer postnatal care visits (Yohannes et al., 2018) have an increased risk of early introduction of complementary foods. These factors call for stakeholders to examine the communication strategy to empower the household members to support the caregivers holistically.
Importantly, this study provides insights into the complex household factors influencing the introduction of solid, semisolid and soft foods using multiyear nationally representative data, with social network analysis methods at a household level. The findings of this study are a proxy for the embedded sociocultural context of infant feeding practices. The findings stimulate further in-depth studies describing how unrelated people negatively influence infant feeding and testing what intervention approach works for large households with extended and unrelated members. While describing the complexity of households is a strength, it is acknowledged that households represent just one part of the complex social dynamics that are likely to influence child feeding. Future works might expand the social network analysis methods to examine the influence of other layers, including the cases of neighbourhood, societal and institutional levels. In addition, the relatively small sample size of the narrower age range of 6-8 months and the complex survey design IRENSO ET AL.
| 9 of 13 may have affected power and the ability to detect a significant association such that further associations may have been missed.

| CONCLUSION AND RECOMMENDATIONS
The low proportion of caregivers introducing solid, semisolid and soft foods between 6 and 8 months across survey rounds partly reflects the household structure supporting existing feeding practices. In large households, the primary caregivers do not get the support that enables her to introduce complementary foods in a timely manner with the time and effort given to others, a possible impediment. The presence of nonrelatives or other extended members changes the household structure, increasing the risk of early or late introduction of complementary foods. However, women from nuclear family households or smaller households with extended families with diversity in age and educational status were more likely to introduce complementary foods in a timely way.
In conclusion, the household structure and composition might influence the introduction of solid, semisolid and soft foods by influencing the availability and access of intrahousehold feeding and caregiving resources to the primary caregivers. The higher intrahousehold dependence of nuclear family households facilitates the appropriate introduction of complementary foods; thus interventions empowering each household member help to engage each in caregiving and enhance the quality of support to the primary caregiver. Also, feeding interventions might consider diverse roles and experiences associated with kinship status, noting that the positive influence is limited primarily to the nuclear family members.
Further attention and action might be needed to address the negative influence of expanded and unrelated household members. Furthermore, national infant feeding programmes would likely benefit from considering household demographic diversity, including age and educational status. Finally, infant feeding intervention strategies must acknowledge variations in the sociocultural context that operate across Ethiopia.